HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Otolaryngology–Head and Neck Surgery 156(4)

tracheal secretions and require replacement. Prior studies using adhesive dressings placed around tracheostomies have utilized additional skin adhesives, such as Benzoin, in com- bination with a protective base layer of Skin Prep to better secure the dressings. 16 The use of additional skin adhesives was not explored in this study. A recent retrospective study in a population of pediatric patients with tracheostomies found a significant decrease in the prevalence of TRAPUs associated with the use of silver- containing polyurethane foam dressing. 5 Another prospective study in a similar patient population utilizing an adhesive poly- urethane foam also saw a reduction in TRAPUs when this foam was utilized as a barrier alongside several other tracheostomy- related interventions. 4 In this study, we utilized a hydrophilic polyurethane foam dressing, PolyMem, after the tracheostomy sutures were removed. At our institution, placement of tra- cheostomy plate sutures is common practice, and these sutures have been observed to make effective placement of a PolyMem dressing underneath the tracheostomy flange difficult. During the audit period, compliance with the use of PolyMem dressing was found to be 100% after suture removal. Patient characteristics, demographics, and comorbidity were compared in the pre- and postintervention groups. No clinically significant differences were noted between these groups or between those with and without TRAPUs. The study is limited by its retrospective design. At this point, further prospective trials should probably focus more on the components of the bundle and the relative contribution of each intervention. Two other potential limitations include observer bias (Hawthorne effect) and regression to the mean in the postin- tervention period. The study data were analyzed starting after July 2013. While excluded from the final comparison analysis, the preintervention TRAPU rate from 2012 to 2013 was similar to the 2013-2014 preintervention year, making a regression to the mean less likely. There was great attention to the TRAPU problem during protocol development in the 1-year preintervention period. We believe that this would make an observer effect less likely but still a potential confounder in studies of this nature. Improper wound classification is also a potential con- founding factor. However, at our institution, we had mul- tiple redundant checks and balances in place for wound examination and review before a case was finally deter- mined and validated to be a TRAPU. Specifically, an ulcer was initially detected by the floor RN or physician and subsequently reviewed by the RN unit leader and then the WOCN-certified nurse, with a fourth layer of review at the WOCN monthly committee. One case pre- sented to the WOCN work group in the preintervention period included some extended discussion over whether the wound should be classified as a pressure ulcer versus a nonhealing elongated tracheostomy incision. This case was excluded from the final TRAPU total to ensure the validity of the data. Last, the perioperative care of percutaneous dilatational tra- cheostomies was specifically not studied, and the implications

of adapting this study protocol to patients who have received a percutaneous dilatational tracheostomy were discussed previ- ously. Again, although not studied specifically, the applica- tion of the prescribed perioperative tracheostomy care protocol to open tracheostomies performed in an intensive care setting, as opposed to an operating room setting, should be straightforward. Indeed, one could anticipate that a similar association with improvement in the incidence of TRAPUs would be observed in this patient group, although no data are presented here to support this assertion. Implications for Practice The reduction of TRAPUs holds particular importance as part of the overall goal of improving global tracheostomy care. In our study, TRAPUs were associated with a signifi- cantly increased length of stay in the hospital. Use of a 4- component institution-wide standardized perioperative tra- cheostomy care bundle was associated with a significantly lower rate of hospital-acquired tracheostomy-associated pressure ulcers. The overall adherence to the study protocol was found to be acceptable. The impact of any single inter- vention within the protocol was not studied and could be an area of further study. Creating bundles for other aspects of tracheostomy care, including outpatient care, are potential areas for further research. 17 The protocol proposed in this study may be adapted for trial at other institutions with dif- ferent practice patterns with regard to tracheostomy. The bundle could likely be generalized to patient populations excluded in this study. We would expect that pediatric tra- cheostomies certainly could receive benefit from similar skin barrier protection protocols. Such care is routinely given to this age group at our institution. Many of the con- cepts are probably applicable to percutaneous tracheos- tomies but would require some adaptation due to the nature of the procedure. Utilization of standardized posttracheost- omy care bundles can have a positive impact on the care of patients with tracheostomies. We encourage its implementa- tion at other institutions as well as further investigative trials. Author Contributions Thomas R. O’Toole , data analysis, manuscript writing, final approval; Natalie Jacobs , study design, interpretation of data, analysis, manuscript writing and revision, final approval; Brian Hondorp , study design, manuscript writing and revision, final approval; Laura Crawford , study design, manuscript review, final approval; Lisa R. Boudreau , study design, manuscript review and revision, final approval; Jill Jeffe , data analysis, manuscript writ- ing and revision, final approval; Brian Stein , data collection and analysis, manuscript writing and revision, final approval; Phillip LoSavio , study design, interpretation of data, analysis, manuscript writing and revision, final approval.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

116